Business Supporters’ Meet Up Registration

Entry fees

Your details

Title

First Name *

Last Name *

Address 1 *

Address 2

Address 3

Town *

County

Country

Postcode *

Home Phone

Mobile Number

By providing your mobile phone number above, you understand that we may contact you by SMS in relation to this event. In order for us to communicate with you via SMS, your number will be passed to a third party company who will act on our behalf. No other details will be passed on and your information will not be used to contact you for any other purpose. If you would prefer not to receive updates via SMS or change your mind in the future, please contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk. Please note that we may continue to contact you about this event via SMS in case of emergency.

Email *

By providing your email address above you understand that we may email you in relation to this event. In order for us to communicate with you via email, your name and email address will be passed to a third party company who will act on our behalf. No other details will be passed on and your information will not be used to contact you for any other purpose. If you would prefer not to receive updates via email or change your mind in the future, please contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk. Please note that we may continue to contact you about this event via email in case of emergency.

Taking Part With

Register additional people?

Would you like to register additional people?

Team Name

Additional participant 1 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 2 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 3 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 4 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 5 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 6 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 7 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 8 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Additional participant 9 details

Title

First Name

Last Name

Under 16? Yes

Please note that all entrants aged 16 and under must be accompanied by an adult who is a registered participant.

Name of accompanying registered participant (if participant is under 16)

Address 1

Address 2

Address 3

Town

County

Country

Postcode

Home Phone

Mobile Number

Email

Gift Aid

Yes, I want to Gift Aid my donation and any future donations I make to Kirkwood Hospice.

Declaration

Accept Declaration * Yes

Help us with our marketing in the future

How did you hear about us

How did you hear, if other

Your communication preferences

Kirkwood Hospice will collect a limited amount of data from you if you choose to sign up for our newsletter, register for an event, fundraise, make a donation or take part in our lottery. We will only use your information to provide you with information or updates that we believe are relevant to you. You can let us know at any time if you would prefer not to receive information from us anymore. Simply contact us on: 01484 557911 or email: events@kirkwoodhospice.co.uk